1. SPECIALIST NURSE SUPPORT IN PRIMARY CARE
VUNERABLE POPULATIONS AND PALLIATIVE CARE
Rachael Walker
NP- Adult/Older Adult (Renal)

2. OVERVIEW Kidney Disease
How this relates to palliative care and vulnerable populations
Why integrate?
The Model
The Patients
The Outcomes
How could this model be used in Palliative Care?

3. ESKD Pt’s on dialysis – 15.4% die each year >75 years – 25%
High CVD Risk
High Symptom Burden
Decreased quality of life

4. Slide courtesy of Dr. Kjellstrand
BREAST
CANCER
HIV
PROSTATE
CANCER
THE DEATH-RATE
WAS THREE TIMES
THAT OF BREAST
CANCER AND HIV,
TWICE THAT OF
PROSTATE CANCER
Slide courtesy of Dr. Kjellstrand
Compare outcomes to something patient can relate too! Breast CA and Prostate CA.
HEMO

6. VUNERABLE POPULATIONS
Over 50
Maori
Pacific
Diabetes / Hypertension /Weight /Smoke
Family History
Less Access
“Hard to Reach”

7. PREVENTION Prevention of ESKD is (FAR, FAR, FAR, FAR) better than ……
Lets re-change our focus

8. WHY GO TO PRIMARY CARE? Integration Collaboration Removing Silo's
Effective Communication
Better, Sooner, More Convenient Care
Up-skilling other staff
Why not?

9. THE MODEL Secondary Care Nurse (Me) 2 Practices High Dep Areas
Working together with Practice Nurses
Identifying High Risk Patients
Holistic Initial Assessment
Intensive Management
Continuity and Follow-Up

10. ENGAGEMENT Stakeholder Hui Practice Hui Invitation from GP
Phone Call follow-up Practice Nurse
Phone Call /Door knock - follow-up Specialist Nurse
1st Assessment – Primary Care or Home

11. THE PATIENTS High Risk Diabetic Hypertensive Albuminuria/Proteinuria
At risk of /with CKD

12. THE DEMOGRAPHICS 71% Maori 19% Pacific 10% NZE
Age (>50% yrs)
10/52 had eGFR< 45ml/min
>50% HbA1c >10% (86mmol/mol)
90% Obese
75% High CVD Risk

13. INITIAL ASSESSMENT Assess knowledge
Assess self-management & health literacy
Assess current health
Assess current lifestyle factors
Clinical markers
Physical Assessment
Medication Review
Develop Care Plan

14. SELF-MANAGEMENT Knowledge Involvement Care-Plan Monitor and Respond
Impact
Lifestyle
Support

15. FLINDERS CHRONIC CONDITION PROGRAM

16. INTENSIVE MANAGEMENT PHASE
Initial Plan
2 weekly reviews – Rapport & Trust
Education – Talk properly
Monitoring
Support
Reassess initial Plan
Referrals –Dietician, Diabetes, Exercise, Counselling, Out-reach nurses, Other providers

17. FOLLOW-UP PHASE At 12 weeks Re-assess
Are we at target
Have we reached our goals
More education
Any other support
Re-plan – 3 months / 1 month/ 2 weeks
Rechecks/Re-establish Goals and Plan

18. HOW LONG FOR? 12 month Pilot Review formally 3 monthly
Continue with Practice Nurse
Patient Self-management –on-going

19. OUTCOMES
Patient
Whanau
Practice Nurses
GP’s
Secondary Care

20. PATIENT Engagement Participation Better knowledge
Able to understand Changes
Lifestyle Changes

21. KNOWLEDGE CHANGE

22. LIFESTYLE CHANGE

23. CLINICAL CHANGES Statistically Significant Improvement in: ACR
Systolic BP
Diastolic BP
HbA1c
BMI
Smoking Cessation
Self Management

24. WHANAU Extra Recruits Screening and Awareness Lifestyle Changes
Exercise
Nutrition
Awareness
Knowledge – Shared

25. PRIMARY CARE Practice Nurses GP’s
Knowledge
Up-skilling
Self-management
GP’s
Indirectly The Same
Relationships /Open lines / Better communication

26. SECONDARY CARE Knowledge Up-skilling Awareness Relationships
Open/lines/communication

27. HEALTH CARE DOLLAR
$80,000 /ANNUM
Hospital admissions
Complications

28. THE MODEL
Chronic Conditions
Diabetes
CVD Risk
Hypertension

29. PALLIATIVE CARE?
How could this model work for you?

30. WORKSHOP QUESTIONS
Is this a role?
If it’s a role – where does it sit?

31. How do you ensure leadership?

32. What is the role of specialist palliative care?

33. How do you promote integration?

34. Who will benefit most?

35. How will you know if inequalities have been reduced?